Gould Dinah J, Moralejo Donna, Drey Nicholas, Chudleigh Jane H, Taljaard Monica
School of Healthcare Sciences, Cardiff University, Eastgate House, Cardiff, Wales, UK.
Cochrane Database Syst Rev. 2017 Sep 1;9(9):CD005186. doi: 10.1002/14651858.CD005186.pub4.
Health care-associated infection is a major cause of morbidity and mortality. Hand hygiene is regarded as an effective preventive measure. This is an update of a previously published review.
To assess the short- and long-term success of strategies to improve compliance to recommendations for hand hygiene, and to determine whether an increase in hand hygiene compliance can reduce rates of health care-associated infection.
We conducted electronic searches of the Cochrane Register of Controlled Trials, PubMed, Embase, and CINAHL. We conducted the searches from November 2009 to October 2016.
We included randomised trials, non-randomised trials, controlled before-after studies, and interrupted time series analyses (ITS) that evaluated any intervention to improve compliance with hand hygiene using soap and water or alcohol-based hand rub (ABHR), or both.
Two review authors independently screened citations for inclusion, extracted data, and assessed risks of bias for each included study. Meta-analysis was not possible, as there was substantial heterogeneity across studies. We assessed the certainty of evidence using the GRADE approach and present the results narratively in a 'Summary of findings' table.
This review includes 26 studies: 14 randomised trials, two non-randomised trials and 10 ITS studies. Most studies were conducted in hospitals or long-term care facilities in different countries, and collected data from a variety of healthcare workers. Fourteen studies assessed the success of different combinations of strategies recommended by the World Health Organization (WHO) to improve hand hygiene compliance. Strategies consisted of the following: increasing the availability of ABHR, different types of education for staff, reminders (written and verbal), different types of performance feedback, administrative support, and staff involvement. Six studies assessed different types of performance feedback, two studies evaluated education, three studies evaluated cues such as signs or scent, and one study assessed placement of ABHR. Observed hand hygiene compliance was measured in all but three studies which reported product usage. Eight studies also reported either infection or colonisation rates. All studies had two or more sources of high or unclear risks of bias, most often associated with blinding or independence of the intervention.Multimodal interventions that include some but not all strategies recommended in the WHO guidelines may slightly improve hand hygiene compliance (five studies; 56 centres) and may slightly reduce infection rates (three studies; 34 centres), low certainty of evidence for both outcomes.Multimodal interventions that include all strategies recommended in the WHO guidelines may slightly reduce colonisation rates (one study; 167 centres; low certainty of evidence). It is unclear whether the intervention improves hand hygiene compliance (five studies; 184 centres) or reduces infection (two studies; 16 centres) because the certainty of this evidence is very low.Multimodal interventions that contain all strategies recommended in the WHO guidelines plus additional strategies may slightly improve hand hygiene compliance (six studies; 15 centres; low certainty of evidence). It is unclear whether this intervention reduces infection rates (one study; one centre; very low certainty of evidence).Performance feedback may improve hand hygiene compliance (six studies; 21 centres; low certainty of evidence). This intervention probably slightly reduces infection (one study; one centre) and colonisation rates (one study; one centre) based on moderate certainty of evidence.Education may improve hand hygiene compliance (two studies; two centres), low certainty of evidence.Cues such as signs or scent may slightly improve hand hygiene compliance (three studies; three centres), low certainty of evidence.Placement of ABHR close to point of use probably slightly improves hand hygiene compliance (one study; one centre), moderate certainty of evidence.
AUTHORS' CONCLUSIONS: With the identified variability in certainty of evidence, interventions, and methods, there remains an urgent need to undertake methodologically robust research to explore the effectiveness of multimodal versus simpler interventions to increase hand hygiene compliance, and to identify which components of multimodal interventions or combinations of strategies are most effective in a particular context.
医疗保健相关感染是发病和死亡的主要原因。手部卫生被视为一种有效的预防措施。这是对先前发表的综述的更新。
评估提高手部卫生建议依从性策略的短期和长期成效，并确定手部卫生依从性的提高是否能降低医疗保健相关感染率。
我们对Cochrane对照试验注册库、PubMed、Embase和CINAHL进行了电子检索。检索时间为2009年11月至2016年10月。
我们纳入了随机试验、非随机试验、前后对照研究以及中断时间序列分析（ITS），这些研究评估了任何使用肥皂和水或酒精类擦手液（ABHR）或两者来提高手部卫生依从性的干预措施。
两位综述作者独立筛选纳入文献的引文，提取数据，并评估每项纳入研究的偏倚风险。由于各研究间存在实质性异质性，无法进行Meta分析。我们使用GRADE方法评估证据的确定性，并在“结果总结”表中以叙述形式呈现结果。
本综述纳入26项研究：14项随机试验、2项非随机试验和10项ITS研究。大多数研究在不同国家的医院或长期护理机构进行，收集了来自各类医护人员的数据。14项研究评估了世界卫生组织（WHO）推荐的不同策略组合提高手部卫生依从性的成效。策略包括以下方面：增加ABHR的可及性、对工作人员的不同类型教育、提醒（书面和口头）、不同类型的绩效反馈、行政支持以及工作人员参与。6项研究评估了不同类型的绩效反馈，2项研究评估了教育，3项研究评估了诸如标识或气味等提示，1项研究评估了ABHR的放置位置。除3项报告产品使用情况的研究外，其他所有研究均测量了观察到的手部卫生依从性。8项研究还报告了感染或定植率。所有研究均有两个或更多高或不明确偏倚风险来源，最常见的是与干预的盲法或独立性相关。包含但未涵盖WHO指南中所有推荐策略的多模式干预可能会略微提高手部卫生依从性（5项研究；56个中心），并可能略微降低感染率（3项研究；34个中心），两项结果的证据确定性均较低。包含WHO指南中所有推荐策略的多模式干预可能会略微降低定植率（1项研究；167个中心；证据确定性较低）。尚不清楚该干预是否能提高手部卫生依从性（5项研究；184个中心）或降低感染率（2项研究；16个中心），因为此证据的确定性非常低。包含WHO指南中所有推荐策略以及额外策略的多模式干预可能会略微提高手部卫生依从性（6项研究；15个中心；证据确定性较低）。尚不清楚该干预是否能降低感染率（1项研究；1个中心；证据确定性非常低）。绩效反馈可能会提高手部卫生依从性（6项研究；21个中心；证据确定性较低）。基于中等确定性的证据，该干预可能会略微降低感染率（1项研究；1个中心）和定植率（1项研究；1个中心）。教育可能会提高手部卫生依从性（2项研究；2个中心），证据确定性较低。诸如标识或气味等提示可能会略微提高手部卫生依从性（3项研究；3个中心），证据确定性较低。将ABHR放置在使用点附近可能会略微提高手部卫生依从性（1项研究；1个中心），证据确定性中等。
鉴于已确定的证据确定性、干预措施和方法的变异性，迫切需要开展方法学严谨的研究，以探索多模式干预与更简单干预相比在提高手部卫生依从性方面的有效性，并确定多模式干预的哪些组成部分或策略组合在特定背景下最有效。
